Normal Growth PDF

NORMAL GROWTH AND
FACTORS AFFECTING GROWTH
IAP UG Teaching slides 2015‐16 1
DEFINITIONS
• Growth: Net increase in the size or mass of tissues
which is largely due to multiplication of cells and
increase in the intracellular substance.
• Development: Maturation of functions associated
with maturation and myelination of nervous system.
GROWTH: SIGNIFICANCE
• Essential feature that distinguishes a child from an
adult.
• Indicates overall well‐being of a child.
• Reflects the nation’s economic status and public
health system.
FACTORS AFFECTING GROWTH
• Prenatal period • Postnatal period
– Fetal – Genetic
– Placental – Environmental
– Maternal
FACTORS AFFECTING PRENATAL GROWTH
A. Genetic Potential
• Parental trait ‐ Tall parents have tall children
‐ Head size related to parents
• Sex ‐ Boys larger than girls
• Race‐ Growth differs in different races
B. Fetal Growth Factors
Growth Promotion Growth Inhibition
• Insulin like growth factors • Transforming growth factor
(IGF‐I and IGF‐II) (~70%) β (TGF‐ β)
• Epidermal growth factor • Mullerian inhibiting
• Transforming growth substance (AMH)
factor α (TGF‐ α) • Inhibin / Activin family of
• Platelet derived growth proteins
factor
• Fibroblast growth factor
• Nerve growth factor etc.
C. Fetal hormones
•Have predominant role in late gestation
•Insulin and Thyroxine : Important for accretion and
differentiation of tissues
•Glucocorticoids : Required for maturation of organs
like lungs, liver and GI tract
•Note : Influence of Growth hormone on fetal growth is
minimal.
D. Placental factors
•Placenta is essential for nutrition of fetus
•Fetal nutrition is enhanced by
– Increased villous surface area
– Decreased diffusion distance
– Increased dilatation of fetal capillaries
– Decreased resistance of vasculature
E. Maternal factors
–Poor nutrition – Pregnancy Induced
–Anemia Hypertension
–Recent pregnancy – Multiple pregnancy
–High parity – Chronic systemic
–Tobacco, drug, diseases
alcohol intake – TORCH infections
OVERALL REGULATION OF FETAL GROWTH
FACTORS AFFECTING POSTNATAL GROWTH
A. Sex
• Boys have greater
growth potential than
girls
• Girls have early
pubertal height spurt
than boys
• Pubertal height gain is
more in boys
B. Genetic
• Chromosome defect
– Short stature: Down syndrome, Turner syndrome
– Tall stature: Klinefelter syndrome
• Gene mutation
– short stature: Prader‐Willi syndrome, Noonan
syndrome
– Tall stature: Marfan syndrome
C. Environmental
• Nutrition
– PEM, Micronutrient deficiency (Fe, Io, Ca, Zn, VitA,
VitD)
• Infections
– Diarrhea, recurrent RTI, TB, HIV, Malaria, Kala‐azar,
Chronic giardiasis
• Toxins
– Food, environment.
Factors affecting postnatal growth
D. Hormonal
•Growth hormone deficiency
•Hypothyroidism
•Growth hormone resistance
E. Social factors
• Low socio economic status: Poor diet, infections
• Hot and humid climate
• Poor emotional support: Broken family, orphans
• Cultural factors: Religious taboos
• Low parental education: Poor health promotion,
poor nutrition.
LATE CONSEQUENCES OF POOR FETAL GROWTH
(NUTRITION)
Fetal origin hypothesis (Barker’s hypothesis)
•Alterations in fetal nutrition and endocrine status lead
to programming
•Permanent changes in structure, physiology and
metabolism
•IUGR infants have increased risk of diabetes mellitus,
hypertension, hyperlipidemia and coronary artery
disease
LAWS OF GROWTH (I)
• Growth is a continuous
and an orderly process.
• The rate of growth is
not uniform – There are
periods of acceleration,
deceleration and
steadiness.
PHASES OF GROWTH ACCELERATION,
DECELERATION AND STEADINESS
Dotted line: Weight
Solid line: Height
c
c cv cv
c
v v v
• Acceleration (fast) ‐1st Half of gestation, 1st year of
life, Puberty
• Deceleration‐ 2nd year
• Steady rate‐ 6‐9 years of age
ICP MODEL FOR POSTNATAL GROWTH (KARLBERG)
HEIGHT ATTAINMENT DURING EACH PHASE
• Infancy: Starts before birth
and falls off by age 3 to 4 years.
Average total height gain is
45%.
• Childhood: Begins at the end
of the first year of life and
continues to mature height.
Average total height gain is
47%.
• Puberty: This phase starts with
initiation of puberty.
Average height gain is 8%
PREDOMINANT CONTROL
IN EACH PHASE OF GROWTH
• Infancy: Nutrition,
GH, thyroxine
• Childhood: GH and
thyroxine
• Puberty: Sex steroid
and GH.
IAP UG Teaching slides 2015‐16 20 20
LAWS OF GROWTH (II)
Growth pattern of every individual is unique.
• Cephalocaudal
• Distal to proximal
LAWS OF GROWTH (III)
•Different tissues of the
body grow at different rates
•General growth: Rapid
during fetal life, first 1‐2 y
and at puberty
•Brain and head: Rapid
during late fetal and early
postnatal life
At birth 70%, at 2 y 90% of
adult.
LAWS OF GROWTH (II)
100% 100%
age years
Brain Growth Somanic Growth
100% 100%
age years
Lymphoid Growth Gonads Growth
• Lymphoid – maximum growth during mid‐
childhood (4‐8y) Large tonsils and lymph nodes
• Gonads – grow at pubescence only
PERIODS OF GROWTH
Prenatal period Postnatal period
• Ovum : 0‐1w Newborn: Birth to 28 days
• Embryo : 2‐8w Infancy: First year
• Fetus : 9w ‐birth Toddler: 2‐3y
• Perinatal period : 22wk Preschool: 4‐6y
of gestation to 7days School age: 7‐12y
after birth. Adolescence:10‐18y
PRENATAL GROWTH
Embryonic period Fetal period
10wk: External genitalia
• 2wk: Bi‐laminar embryo distinguishable
• 3wk: Tri‐laminar embryo, 20wk: 460gm, 19cms, lower
Heart pumping begins limit of viability
• 4wk: 4cms, human shape, 24w – Primitive alveoli,
arm‐leg buds surfactant production
• 5‐8wk: Major organ system 25wk: 900gm, 25cm, 3rd
development trimester begins
• 9wk: 9g, 5cm. Fetal period 38wk: Term, weight triples,
begins. length doubles from that of
25 w of gestation
PARAMETERS OF GROWTH
• Weight.
• Length <2 y or Height >2 y.
• Head circumference (HC), Chest circumference (CC).
• Upper segment to lower segment (U:L) ratio.
• Arm span (AS).
AVERAGE GROWTH PARAMETERS AT BIRTH
• Weight: 3 Kg
• Length: 50 cm
• U/L ratio: 1.7
• HC: 35 cm
• CC: 33 cm
POSTNATAL GROWTH : WEIGHT
Age group Weight gain
0‐3 m 25‐30g/day
4m‐1 yr. 400g/month
2yr – Pubertal growth spurt*
2‐3 Kg/y
or
[Wt. in Kg = (Age in years +4) X 2]
• Weight doubles at 5m, triples at 1 y, quadruples
at 2y
* Boys 12 y, girls 10 y.
POSTNATAL GROWTH: LENGTH/HEIGHT
Age group Height velocity
0‐3 m 3.5cm/m
4‐6m 2cm/m
7‐9m 1.5cm/m
10‐12m 1.2cm/m
13‐24m 1cm/m
3‐10 yr.* 5‐6cm/y
* Weech’s formula: Ht in cms = (Age in years X6)
+ 77
POSTNATAL GROWTH: ADOLESCENCE
PARAMETER EARLY MIDDLE LATE

Age (years) 9-13 14-16 17-20
Weight gain/Year 2Kg 3.5kg 1kg
Height gain/year 6-8cms 8-10 cm 2-3 cm
SMR* stages 1,2 3,4 5
* Sex maturity rating
Mean pubertal height gain : Boys‐27 cm, girls‐25 cm
Mean pubertal weight gain : Boys 29kg, girls 24 kg
POSTNATAL GROWTH
UPPER SEGMENT TO LOWER SEGMENT RATIO
Age Ratio
Birth 1.7
6m 1.6
2yr 1.4
3yr 1.3
4yr 1.2
6yr 1.1
10yr 1.0
Adults 0.9
>6m age U/L ratio = 1.6 (Age in years X0.1)
POSTNATAL GROWTH
HEAD CIRCUMFERENCE (HC)
Age Rate of increment
Birth‐3m 2cm/m
4m‐6m 1cm/m
7m‐12m 0.5cm/m
2nd y 1cm/y
>2y 0.5cm/y
By 12 y 52 cm
POSTNATAL GROWTH
CHEST CIRCUMFERENCE (CC)
Birth: HC > CC
1 year: HC= CC
> 1 year: HC < CC
POSTNATAL GROWTH: ARM SPAN (AS)
Birth to 5 y Ht 2cm > arm span
5‐10 y Ht 1cm > arm span
10 y Ht = arm span
Adults Ht 2cm < arm span
POSTNATAL GROWTH: SKELETAL MATURATION
•Steady in childhood, accelerates at puberty
•Closely correlates with sexual maturation
•Maturity indicated by epiphyseal closure
•Complete in boys at 22 y, girls at 18 y
Preferred areas for bone age estimation by
radiography
Birth‐3m knee and ankle
3‐9 m Shoulder
1‐13 y Hands and wrists
12‐14 y Elbow and hip
POSTNATAL GROWTH – DENTITION
Primary teeth (20) Age at eruption
Central incisors 5m to 8m
Lateral incisors 7m to 11m
Canines 16m to 20m
I Molar 10m to 16m
II Molar 20m to 30m
Approximate assessment
Expected number of teeth = Age in months ‐ 6
POSTNATAL GROWTH – DENTITION
Permanent teeth (32) Age at eruption
I molars 6 to 7 y
Incisors 6 to 8 y
Canines 9 to 12 y
Premolars 9 to 12 y
II Molar 12 y
III Molar ≥ 18 y
GROWTH STANDARDS
• Norms of growth represented as tables or charts
• Derived from large cohort of healthy children by
cross sectional or longitudinal studies
• Tables are useful as easy ready references
GROWTH CHARTS
• Superior to tables to
diagnose early
deviations in growth
• Distance growth charts
reveal the growth
acquired till the date of
last evaluation
HEIGHT VELOCITY CHARTS
• Height velocity: Rate of height
increment per unit time and
• Indicates periods of
acceleration, deceleration and
steadiness
• Most useful for early
identification of growth
faltering
DISTANCE GROWTH CHARTS
• Growth parameters
are presented in
graphical manner
• Age along the X axis
and measurements in
the Y axis
• Charts have 5 or 7
percentile curves
representing the
distribution of the
growth parameters
GROWTH PARAMETERS IN GROWTH CHARTS
• Weight for age
• Height/length for age
• Head circumference for age
• Weight for length/height
• Body mass index
Each parameter separate for boys (Blue) & girls (pink)
PLOTTING HEIGHT ON A GROWTH CHART
• 8 years old boy,
• Height: 120 cm,
• Draw an imaginary line
along the X‐axis till the
age (8y) of the child.
• Then extend the
imaginary line along
the Y‐axis till the height
(116 cm) of the child
• Mark the point
RECOMMENDED GROWTH CHARTS
WHO, derived from MGRS Revised IAP Growth charts,
study 0‐5 years 2015
Height, weight, HC for 0‐5 y
Weight for height for 0‐5 y Height, weight, BMI for 5‐18 y
WHO GROWTH CHARTS ‐ 2006
• Ideal growth charts that provide data on how
children should grow
• Internationally usable standard growth charts
• Multi‐center Growth Reference Study (MGRS) from 5
Continents.
• Study sites – US, Brazil, Ghana, Oman, Norway, India.
WHO GROWTH CHARTS ‐ 2006
• Derived from children raised under optimal
conditions for growth such as:
– Exclusive breast feeding
– Healthy environment
– Minimal infection
– Nonsmoking mothers
STATISTICS USED IN DESCRIBING GROWTH
• Normal: Healthy.
• Median: Value above and below which 50% of
observations lie.
• Mode: Value having highest number of observations
• Mean: The average value of observations.
• Standard deviation or Z score: The extent to which
observed values cluster near the mean.
NORMAL DISTRIBUTION (GAUSSIAN) CURVE
• Symmetrical bell shaped curve in which 50% of the
observations lie above & 50% below a central line
which is the 50th percentile or median
• Values below 3rd (‐2SD) and above 97th (+2SD)
percentile are abnormal.
UNDERSTANDING OF PERCENTILES
• 8 years old boy,
• Height: 120 cm,
• 10th percentile for his
age and sex
• 10% of boys aged 8y in
the reference
populations are
shorter and 90% are
taller than the index
child
THANK YOU

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NORMAL GROWTH AND

PARAMETER EARLY MIDDLE LATE

Height gain/year 6-8cms 8-10 cm 2-3 cm

SMR* stages 1,2 3,4 5

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